Provider Demographics
NPI:1902497100
Name:BURGETT, KENNETH BENJAMIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:BENJAMIN
Last Name:BURGETT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3070 DINDLE DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-0136
Mailing Address - Country:US
Mailing Address - Phone:770-265-4280
Mailing Address - Fax:
Practice Address - Street 1:501 S SHARON AMITY RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-0035
Practice Address - Country:US
Practice Address - Phone:704-377-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-30
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11879363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant